California's kids could use a trip to the dentist. One-fourth of children younger than age 12 in California have never even been to the dentist, according to a new Pew Center on the States report that gives California a grade of "C" for the dental health of its children.
One of the major ways to raise that grade is to get children to see a dentist in the first place. That approach should get a big boost when an estimated one million California children get access to dental coverage in 2014 under the national health care reform law.
That raises a big question, according to Jenny Kattlove, director of strategic health initiatives at the Children's Health Partnership.
"You're looking at almost a million children with additional coverage, but Medi-Cal already has access issues," Kattlove said. "In California, most dentists are just not taking Medi-Cal patients anymore."
Children's health advocates worry that access is likely to get even tighter in the next year or so. Already, California's reimbursement rates for Medi-Cal are among the lowest in the nation, which causes reluctance to care for Medi-Cal patients among many providers. That access problem will not be helped by the state's plan to further reduce rates by 10%. Also, if legislators adopt the May budget revision plan, an additional 870,000 children will be moved out of Healthy Families, the state's Children's Health Insurance Program, and into a Medi-Cal managed care plan, starting Jan. 1, 2012.
"The move from Healthy Families to Medi-Cal is certainly something to be concerned about because of Medi-Cal's access issues," Kattlove said. "California has a long way to go to improve dental health."
One Possible Answer
The combination of limited health care providers and greater demand is a tricky equation, especially in rural and underserved areas, Kattlove said.
She knows one direction that might work. "We need to look at expanding the work force," she said. That doesn't just mean training new dentists, which can be a lengthy and costly process, according to Kattlove. She envisions a new kind of dental care provider who can meet the basic needs of an immense number of low-income, rural and underserved children in California.
"One of the areas the Pew Center report looks at is authorizing new types of dental health providers," Kattlove said. "They would be trained on narrowly defined parameters, part of a dental team, supervised by a licensed dentist."
It would be similar to the way licensed nurse practitioners handle many health care needs while working under a physician's supervision, she said. The new dental providers could fill kids' cavities, do simple extractions, handle some restorative care and replacement of crowns.
"It's a model that has proven to work in 53 other countries," Kattlove said. In this country, a program was started in Alaska to reach isolated Native American communities. The training for that program is done at the University of Washington.
"At least 10 other states are looking at this new model of care," Kattlove said.
Alaska, Minnesota First
According to Andy Snyder, researcher with the Pew Children's Dental Campaign, Alaska was the first to launch a dental therapist program, but it won't be the last.
"There are two training programs right now in Minnesota, one at the University of Minnesota," Snyder said. "And at the other one at Metropolitan State University. The first class is graduating this month. It's very exciting."
The Minnesota law requires that at least half the patients treated by new dental therapists be Medicaid beneficiaries, according to Snyder. Dental therapist students also are encouraged to settle in underserved areas.
"The way that program is structured, it draws people from those communities that are underserved for dental care, so they have more of a commitment to serve there," he said. "It allows them to go back and serve those communities."
That same logic could be applied to California, Snyder said.
Liz Snow, chief operating officer for the California Dental Association, said the barriers for children to receive dental care in California go beyond economics. In fact, the biggest barriers may be social, she said.
For instance, Latino patients are less likely to see a dentist who doesn't speak Spanish. Children are less likely to get to a dentist, even when they have coverage, if their parents don't have coverage themselves. "There's a question of transportation for beneficiaries, linguistic aptitude, all of those are factors," Snow said. "There's certainly no question the situation in California is bad. And at this point, we haven't yet seen the full impact of the [recent] cuts."
Addressing children's dental needs has to be done on multiple levels, she said. "California is still only at about 65% for [people drinking] fluoridated water," Snow said. "There's no longer any school-based oral health care program. School nurses can't treat students with sealants. Most of these kinds of programs are common in other states.
If California continues to do a poor job of focusing on prevention, she said, that means a lot more dental time and energy will be spent on more expensive crisis care.
A Pound of Prevention
That's where dental therapists can make an impact, Snyder said. Even if California had a sufficient number of dentists, the geographic distribution of those dentists guarantees that a large percentage of Californians can't get dental care, he said.
"You need a base of providers available to treat that population," he said. "You need more providers in those communities. It's a geographic distribution problem."
Snow said CDA has been working with pediatric medical offices to jump-start some basic oral health for kids, to bridge the separation between provider communities. "Most children are entering the system somewhere other than the dentist's office," she said.
Children in California need a basic oral health infrastructure in place, Snow said, "and we haven't had that in the state of California for years. And because of that, we miss out on federal funding, we miss out on a great deal. For us, that's one of the first things to be done."
Snow said CDA has been working with Assembly member Richard Pan (D-Sacramento) on a legislative proposal to address that.
"It's been an issue throughout the nation," Snow said. "Other states have figured out how to put in at least a small effort, to at least hire a couple of people who can focus on dental issues. It is an uphill battle."
It's a battle dentists have fought for years, a struggle that goes far beyond health care provider rates, she said.
"The other dynamic that exists in California is there's not much faith among the provider community because of the constant rate increases and decreases, and fighting every year to save the adult dental program. Every year, you don't know if you can save it. That kind of [constant negative] activity sends the message that dental care is not important."
Kattlove added that dental care can be overlooked as a public health issue because it's not life-threatening.
"Clearly, a certain group of children are not getting the dental care they need. And the consequences of that are huge," Kattlove said. "Children end up in the emergency room. Children end up missing school, parents are missing work."
One of the keys to unlocking the problem of children's dental care in California, she said, is to make sure, once children are insured, that providers are available to them.
"We need to be ready with a work force today," Kattlove said. "We need to get our policymakers behind this effort. The state is definitely looking at its health work force issues, and now is the time to fix it. We need to be creative here."